ABSTRACT As a rule, endocervical tumours with signet-ring cell are classed as metastatic extra-genital neoplasms. In a patient aged 45 years, we describe primary cervical signet-ring cell carcinoma (PCSRCC) characterized by prominent endometrial and myometrial involvement, simulating primary endometrial adenocarcinoma with cervical extension. In addition, a review was made of the literature to identify the clinical and pathological features of this rare malignancy.
A 45-year-old woman was referred to our Gynaecology Department due to persistent abnormal vaginal bleeding. Transvaginal ultrasonography showed slight endometrial irregularities in the whole uterine cavity suggestive of endometrial neoplasms. Pelvic magnetic resonance imaging revealed diffuse enlargement of the cervix, which had been replaced by a mass. Induration extended to the parametria and sigmoid colon fat.Histological examination of endometrial curettage and a cervical biopsy revealed a neoplasm characterized by neoplastic signet-ring cells and trabecular structures. Immunohistochemical analysis and molecular studies showed certain findings consistent with a cervical neoplasm, such as positivity to CEA, keratin 7, Ca-125 and p16 and the presence of HPV (Human Papilloma Virus) DNA 18.On examination of the hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy, the lesion replacing the cervix, endometrium and myometrium, revealed the same immunohistochemical findings observed on endometrial curettage and cervical biopsy specimens. Metastases were found in an ovarian cystic lesion and the lymph nodes.
With this report the authors have demonstrated that the spread of cervical adenocarcinoma to the uterine corpus, although rare, may be observed, and that in this instance immunohistochemical and molecular studies can provide sufficient information for accurate diagnosis even on small biopsy specimens.

[Show abstract][Hide abstract]ABSTRACT: We present, in a 47-year-old man, the first case of the signet-ring stromal tumor of the testis. The tumor was located beneath the tunica albuginea surrounded by the testicular tubules and rete testis. It was sharply circumscribed by a thin and irregular fibrous capsule. Histologically, it was composed of cells with a widespread signet-ring cell change separated by fibrous stroma. In some places, the signet-ring cells formed vague Indian files, thus resembling metastatic carcinomas with signet-ring cell morphology. Under high magnification, most of the cytoplasm of the tumor cells was seen to be replaced by an empty clear vacuole which pushed the nuclei to the periphery of the cells. Some of the nuclei were indented by the cytoplasmic vacuoles, others were without indentation. Only in a small area did the tumor show cells without a signet-ring cell change. They looked like epithelioid fibroblasts forming abortive and vaguely tubular structures. Mitoses and necroses were absent. Mucicarmine and PAS stains were negative. Immunohistochemically, the tumor was vimentin positive and it was negative with antibodies to cytokeratins, inhibin, prostatic acid phosphatase, prostate-specific antigen, smooth muscle actin, S-100 protein, EMA and calretinin. The signet-ring stromal tumor of the testis is thus similar morphologically and immunohistochemically to the signet-ring stromal tumor of the ovary. The patient was free of recurrence and metastasis 3 years after the excision.

[Show abstract][Hide abstract]ABSTRACT: Breast cancer metastatic to the cervix and uterus in the absence of extrapelvic foci is a rare finding in the medical literature. Signet ring breast carcinoma is also an unusual neoplasm. We present an asymptomatic 71-year-old woman 2 years status-post modified radical mastectomy for signet ring carcinoma who was found to have metastatic lesions to the cervix and endometrium at the time of a routine gynecological examination. Bone scan as well as computerized tomography of the chest, abdomen, and pelvis failed to locate other metastatic sites. We believe this to be the only reported case of signet ring breast carcinoma metastatic solely to the uterus and cervix. The patient's lack of recent pelvic examination highlights the need for continued gynecological evaluation in patients with breast cancer.

[Show abstract][Hide abstract]ABSTRACT: Extragenital metastases to the endometrium are unusual, but several histologic features have been suggested as highly suggestive or even pathognomonic for this diagnosis. We report an endometrial carcinoma with a prominent signet-ring cell morphology and a diffusely permeative pattern of infiltration, features that have been reported as indicating an extragenital metastasis. To the best of our knowledge, this is the first reported case of a signet-ring cell carcinoma of the endometrium. Gynecological pathologists should be aware of this entity because of its potential primary of metastatic signet-ring carcinoma to be endometrium.

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BackgroundSignet-ring cell carcinoma is an epithelial malignancycharacterized by the presence of cells with a signet-ringappearance. This appearance is due to a large vacuolefull of mucin displacing the nucleus to the periphery.Thus, the pool of mucin in a signet-ring cell mimics theappearance of a finger hole, while the nucleus representsthe face of the ring in profile [1]. Signet-ring cell carci-noma is considered a form of adenocarcinoma [1].Signet-ring cells are most frequently associated withstomach cancer [1], but may be observed in any tissueincluding the prostate [2] bladder, gallbladder [3] breast,and colon [4] as well as in stromal tumours of the ovaryand testis [5].Most signet-ring cell carcinomas in the female genitaltract are extra-genital metastatic neoplasms [3,6-9].Primary signet-ring carcinomas of the female genitalorgans, on the other hand, may be considered a rareevent. In fact, primary signet-ring cell carcinoma of theendometrium has only been observed in 4 previouscases [10-12].Moreover, to the best of our knowledge, no more than14 cases of primary cervical carcinoma containing sig-net-ring cells have been reported in the English litera-ture [13-22].In this paper, we report a new case of primary signet-ring cell carcinoma of the cervix (PSRCC) with promi-nent endometrial and myometrial involvement simulat-ing endometrial adenocarcinoma with extension to thecervix or metastatic extra-genital tumour (OK). Theresults of immunohistochemical and molecular studieshave been reported as ancillary techniques to provideinformation for a more accurate diagnosis of this raremalignancy. In addition, we reviewed the literature toidentify the clinical and pathological features of this raremalignancy.Case presentationThe materials consisted of cervical and endometrialbiopsy specimens, plus specimens from hysterectomywith bilateral salpingo-oophorectomy and pelvic lym-phadenectomy. The specimens were fixed in 10% neu-tral-buffered formalin for a routine light microscopeexamination. The samples were embedded in paraffin,then 3μ sections were cut and stained with haematoxy-lin-eosin. Immunohistochemistry was performed withantibodies anti-Ca 125 (Dilution 1:100, clone: M11,Dako, Glostrup, Denmark), CEA (Dilution 1:200, clone:11-7, Dako, Glostrup, Denmark), anti keratin 7 (Dilu-tion:1:200, clone OV-TL 12/30, Neomarkers, Pleasalton-CA), and p16INK4a(Kit Cinetec p16INK4a, Heidelberg,Germany), Vimentin (Neomarkers, dilution:1:500, clone:V9, Neomarkers, Pleasalton-CA), anti-oestrogen recep-tors (Dilution:1:50, clone: SP1, Neomarkers, Pleasalton-CA), anti-progesterone receptors, (Dilution:1:200, clone:P8R636, Dako, Glostrup, Denmark), Chromogranin A(Dilution:1:2000, clone: LK 2H10+ PHE5, Neomarkers,Fremont-CA) and Synaptophysin (Dilution:1:100, poly-clonal, Cell Marque, Hot Springs, AR, USA), using theavidin-biotin method.Polymerase chain reaction amplification (PCR) wasperformed to evaluate the presence of HPV DNA in thecervical and endomyometrial neoplasm.For DNA extraction, 4 μm-thick histological sectionswere stained with haematoxylin and examined under astereomicroscope. Neoplastic areas were manuallymicro-dissected using sterile scalpels, suspended in abuffer for tissue lysis (Tris HCl 50 mM, pH 9, 1 mMEDTA pH 8.0, 0.5% Tween 20, 5% Chelex 100), andincubated overnight with Proteinase K (0.4 mg/ml) at55°C. After enzyme inactivation by 10 min boiling, DNAextracted was used directly in the PCR mix, withoutfurther purification.HPV-PCR amplification was performed with L1 con-sensus primers Gp5+/Gp6+ [23], giving an expectedPCR product size of 150 bp: these primers, which weredistinct but pooled, have been developed to allow thedetection of a broad spectrum of mucosotropic HPVgenotypes (6, 11, 13, 16, 18, 30-35, 39, 40, 42, 45, 51-53,56, 58, 61, 66). Most of these genotypes are correlatedwith lesions of high oncogenic risk (16,18,45,56 and 58).Five μl of appropriately diluted DNA were combined ina 25 μl reaction mixture containing 10 mM Tris-HCl(pH 9.0), 50 mM KCl, 0.1% Triton X-100, 200 μM ofeach dNTP (Promega, Madison, WI, USA), 0.4 μM ofeach primer, 2.0 mM MgCl2, 1.25 U Taq polymerase(Promega, Madison, WI, USA). Amplification was car-ried out for 40 cycles in an AB 2700 (Applied Biosys-tems, Foster City, CA, USA) thermal cycler. Each cycleof amplification consisted of 1 min denaturation at 94°C, 1 min annealing at 46°C, and 1 min of elongation at72°C. The first cycle was preceded by 7 min denatura-tion at 94°C while the last cycle was followed by a 7min elongation step at 72°C. PCR for human b-globingene was performed to establish the presence of amplifi-able DNA and to exclude the presence of inhibitory fac-tors of the PCR reaction [24]. Sequencing of the GP5+/GP6+ amplimer was performed as follows. PCR reac-tion was slightly modified, using 1 pM of each primer,1.5 mM MgCl2 and 1.25 units of AmpliTaq Gold(Applied Biosystem, Foster City, CA). Amplificationconditions were as previously indicated. PCR productswere purified using the NucleoSpin®Extract II kit(Macherey-Nagel, Düren-Germany) according to manu-facturer’s instruction. DNA sequencing was performedby Eurofins MWG Operon/M-Medical (Milano, IT).Sequencing results were verified in our laboratory inboth sense and anti-sense directions using DNA STARGiordano et al. World Journal of Surgical Oncology 2012, 10:7http://www.wjso.com/content/10/1/7Page 2 of 9

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PC software (Lasergene, Madison, WI USA). HPV typewas determined using the BLAST (Basic Local Align-ment Search Tool) Search function of the PapillomaVirus Episteme (PaVE) Database (http://pave.niaid.nih.gov).The patient was a 45-year-old woman who had beenreferred to our Gynaecology Department because of per-sistent abnormal vaginal bleeding. Gynaecological exam-ination revealed diffuse enlargement of the cervix whichhad been replaced by an exophytic ulcerated, reddishlesion. Transvaginal ultrasonography showed slightendometrial irregularities in the whole uterine cavitysuggestive of endometrial neoplasms. Pelvic magneticresonance imaging revealed diffuse enlargement of thecervix which had been replaced by a mass. Indurationextended to the parametria and sigmoid colon fat. (Pre-operative FIGO stage: IIB).Endometrial curettage and cervical biopsy were per-formed. On histological examination, both specimensrevealed the presence of a neoplasm characterized byneoplastic signet-ring cells and trabecular structures(Figure 1).Periodic acid Schiff (PAS) and blue alcian stainsrevealed the presence of intracellular mucin in the sig-net-ring cells.Immunohistochemical analysis showed findings consis-tent with a primary cervical neoplasm, including positivityto keratin 7, Ca-125, CEA, and p16 and negativity toVimentin in both endometrial (Figure 2) and cervicalbiopsy (Figure 3), oestrogen and progesterone receptors.The cervical origin of the neoplasm was also supported bythe presence of HPV DNA (Figure 4) by Polymerase chainreaction amplification (PCR) and sequencing analysiswhich demonstrated the presence of HPV 18 (Figure 5).The cervical origin of the neoplasm was furtherdemonstrated by the absence of other neoplasms onoral endoscopy, thorax, abdominopelvic computedtomography, colonoscopy and mammography study.The absence of immunoreactivity to ChromograninA and synaptophysin excluded neuro-endocrinedifferentiation.A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and selective pelvic lymphadenectomy,omentectomy and resection of sigmoid colon wereperformed.Macroscopic examination of the hysterectomy speci-men revealed an ulcerated cervical mass and irregulari-ties in the whole endometrial cavity. On cut section,white neoplastic tissue extended through the entiremyometrial wall thickness to involve the uterine serosa.Examination of bilateral salpingo-oophorectomy speci-mens revealed a right ovarian cystic lesion with multiplewhite nodules on its surface. White neoplastic noduleswere also observed in the sigmoid colon fat.Microscopic evaluation confirmed the initial diagnosisof primary cervical adenocarcinoma with signet-ring ele-ments and prominent endometrial and myometrialinvolvement.Characteristically, the entire endometrial mucosa andmyometrial wall thickness were involved. The endome-trial component consisted of trabecular and glandularstructures and signet-ring elements which accounted for30% of the tumour (Figure 6A). In the myometrial part,the tumour was characterized by lakes of mucus inwhich neoplastic elements were floating (Figure 6B). Allthe nodules observed in the sigmoid colon fat and thecystic lesion of the right ovary were metastases of thecervical neoplasm, while other metastases were observedin 3 pelvic lymph nodes.DiscussionIt is universally recognized that adenocarcinomaswhich accumulate mucin in large single or aggregatedFigure 1 On histological examination both endometrialcurettage (A: Haematoxylin-Eosin × 100) and cervical biopsy(B: Haematoxylin-Eosin × 200) specimens revealed thepresence of a neoplasm characterized by neoplastic signet-ringcells and trabecular structures.Giordano et al. World Journal of Surgical Oncology 2012, 10:7http://www.wjso.com/content/10/1/7Page 3 of 9

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intracytoplasmic vacuoles displacing the nucleus per-ipherally, correspond to signet-ring cell carcinoma.In certain tissues these malignancies are generallycharacterized by poor prognosis [25,26].Several researchers have reported artifactual vacuolesand non-adenocarcinomatous neoplasms in variousorgans and tissues, including the prostate, lymphomasand the ovaries [27-30].Non-neoplastic endometrial stromal signet-ring cellsmay be observed during decidualization, when endome-trial stromal cells acquire cytoplasmic vacuoles second-ary to the accumulation of glycogen and glycoproteins[31,32]. A lack of staining for mucin as well as immuno-histochemical non-reactivity for epithelial markers typi-cally allows recognition of these non-neoplasticelements.The presence of signet-ring cells in a carcinomawithin the cervix or in other organs of the genital tractstrongly suggests the possibility of a metastasis from aprimary tumour of the breast or gastrointestinal tract[3,6-9]. Immunohistochemical and molecular studieshave provided information for differential diagnosis insome instances. Monteagudo et al observed that in themajority of cases, the signet-ring variant of breast cancermetastatic to the ovary showed positivity to gross cysticdisease fluid protein -15 (GCDFP-15) [33]. In contrast,immunoreactivity to colorectal antigens such as CEA,CDX-2 (20) and CK 20 [19] in a cervical lesion does notrule out a diagnosis of primary cervical carcinoma.As well as cervical cases, adenocarcinomas expressmarkers common to gastric, intestinal and pancreatobili-ary epithelial cells [34]. Moreover, simultaneous positiv-ity to CEA and keratin 7 do not differentiate betweenPCSRCC and mammary metastatic malignancy [35].To the best of our knowledge, only 14 cases of pri-mary cervical carcinoma containing signet-ring cellshave been reported in the English literature [13-22](Table 1).The majority of the patients in these reports are post-menopausal women [13,14,16,19,22]. ConspicuousFigure 2 Immunohistochemical analysis of endometrial neoplasm showed findings consistent with a primary cervical neoplasm, i.e.positivity to Ca-125 (A × 200), CEA (B × 100), and p16 (C × 200) and negativity to Vimentin (D × 200).Giordano et al. World Journal of Surgical Oncology 2012, 10:7http://www.wjso.com/content/10/1/7Page 4 of 9

woman by Moritani et al [17], while partial entericimmunophenotype with consistent expression of CDX2marker has been described by McCluggage et al [20].Oestrogen and Progesterone receptors have beentested in only 4 previous cases [15-17,19,21] and thesewere present only in one example [16].Neuroendocrine differentiation by using neuroendo-crine markers such as Chromogranin A [19] and bothChromogranin A and Synatophysin [16] have beendemonstrated in two cases, but these markers werenegative in our case.In our case, as well as in some previous publishedexamples of the PCSRCC, the primary cervical originwas supported by the presence of HPV DNA usingmolecular analysis [15,22] and by P16 immunoreactivity[20,22], which may be considered a surrogate marker forHPV infection [36].Prognosis for PCSRCC is not well understood becauseof its rarity [13-22]. Moreover, is not possible to drawconvincing conclusions about the prognostic significanceof signet-ring component in endocervical carcinomasince the follow-up period in the majority of the previouscases reported in the literature is either too short [15-17]or was not reported [20,22] (Table 1). However, in ouropinion, prognosis in this rare malignancy should be con-sidered poor at more advanced stages of the disease.This hypothesis is supported by data in the literaturewhich show that all patients with an advanced stage ofdevelopment of neoplasm (stage III sec FIGO) diedfrom the disease after only 10 [13] or 18 months [15,19]and 7 weeks and 2 months from diagnosis [21]. More-over, in these examples of PRSCC, the authors had alsodocumented that this rare malignancy showed resistanceto radiotherapy and/or chemotherapy [13,15,19,21]. Incases observed by Veras et al, the PCSRCC were charac-terized by widespread metastatic disease with systemicthromboembolic phenomena (Trousseau syndrome) andboth patients expired shortly after initiation of che-motherapy (Table 1). In these cases, Veras et alexcluded metastatic adenocarcinomas of the upper gas-trointestinal tract origin because of the presence of HPVDNA by in situ hybridization [21].In cases with a lower stage of development (stage Ibsec FIGO) prognosis is better. Indeed, in the casesdescribed by Mayorga et al and Insabato et al, thepatients showed no evidence of disease several monthsafter diagnosis [14,18].Generally, cervical carcinoma spreads to the parame-tria and/or vagina. In our case, the neoplasm hadinvolved the uterine corpus and showed prominentendometrial and myometrial infiltration simulating pri-mary endometrial adenocarcinoma with cervical exten-sion. Data from the literature reveal that the spread of???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????Figure 5 Sequence alignment illustrating 100% identitiesbetween Human papillomavirus type 18 reference sequence(PAVE entry X05015.1) and HPV DNA from both endometrialand cervical specimens. (End: endometrial lesion)Figure 6 Microscopic examination of hysterectomy specimenrevealed the presence of neoplasm with endometrial andmyometrial involvement. The endometrial component of theneoplasm was formed by predominant trabecular and glandularstructures (A: Haematoxylin-Eosin × 40) In the myometrial part, thetumour was characterized by lakes of mucus in which neoplasticelements floated (B: Haematoxylin-Eosin × 100).Giordano et al. World Journal of Surgical Oncology 2012, 10:7http://www.wjso.com/content/10/1/7Page 6 of 9